DVT Service - Patient Record Card GP Care
1. Personal Details
a) Summary Information
Name (in full):Date of Birth: / NHS number:
Registered Practice: / Referring GP:
b) Detailed information (not required if D-dimer test is negative)
Contact No(s): / Mobile Phone:Home Address:
Practice Tel No: / Practice Fax No:
Current Medication:
Patient History
Patient Presenting with (circle as appropriate): / Right Leg / Left Leg / Swollen / Painful / Red
2. Wells Score / D-dimer Test
a) Tests
Date Tests Performed: / Wells Score:D-dimer Test Result: / Positive D-dimer / Negative (delete as appropriate; if negative go to Section 6)
D-dimer performed by: (identify practice and clinician)
b) Pre-Scan Clexane injection(s) / Weight: / kg / Date:
Date initial injection: / Dosage: / Administered by:
Date pre scan inj / Dosage: / Administered by: / (OOH)
Date pre scan inj / Dosage: / Administered by: / (OOH)
3. Ultrasound Appointment (Call GP Care on 0845 625 2100 to book appointment)
Date of Appointment: / Time: / Location:4. Ultrasound Result (GP Care Ultrasound Service to complete)
Ultrasound Result: / Positive DVT / Category of DVT: / Calf VeinNegative / Proximal Vein
5. Anticoagulation (Clexane/Warfarinisation)
See Separate Sheet to follow6. Discharge and Patient Management Plan from GP Care DVT Service
(following discharge please fax this Record Card to the Patient’s Registered Practice)
Date of Discharge: / Signature of Clinician:How long should Patient stay on Warfarin? / mths / Date next INR Test due:
Notes:
Ensure patient is transferred to pink slip/yellow book system for ongoing Warfarin management.
PLEASE ADVISE PATIENTS THAT THEY SHOULD TAKE THIS RECORD CARD TO ALL APPOINTMENTS
At completion of D-dimer or discharge please fax this Record Card to GP Care on 0117 956 2224
At transfer of Patient to Out Of Hours please fax this Record Card to either:
Frendoc on 0117 975 3973 Brisdoc on 0117 903 0004
Author: RT/LA Page 1 of 1 November 2009 Version 1